V5-11: Intrasinusal dissection and 3-mm off-clamp renal tumorectomy by retroperitoneoscopy
European guidelines recommend Nephron Sparing Surgery in pT1 tumours. Retroperitoneoscopy enables rapid and easy access to the renal hilum. Minimizing warm ischemia time is important to reduce kidney damage without compromising the quality of the tumor resection. The 3-mm instruments can decrease surgical aggression of the abdominal wall.
We present the case of a 62-year-old patient, with a history of arterial hypertension, diagnosed by CT scan with a 25 mm renal tumor in the medial side of the posterior aspect of the left kidney. The decision was made to perform left partial nephrectomy by retroperitoneoscopy.
Three 3mm trocars were inserted in a diamond shape position including one for the 3mm laparoscope. Intrasinusal dissection was performed and Rummel tourniquets placemet without closing them in the primary and secondary arteries. The tumor was enucleated without clamping. The surgical time was 150 minutes with a blood loss of 250 ml. There were no complications. The patient was discharged at day 3. The pathological anatomy was a papillary renal cell carcinoma, stage pT1a, with negative margins._x000D_ Between January 2011 and January 2015, we performed 50 partial nephrectomies by retroperitoneoscopy. The male/female ratio was 4.87, the mean age was 62 years and the mean tumor size was 34,36 mm. The zero ischemia technique was performed in 39 cases (78%). The average surgical time was 163,1 minutes, and the mean blood loss was 400,8 mL. Five cases required transfusions. One reoperation (IIIb Clavien) and one conversion to open surgery (IIIb Clavien) were necessary. The mean stay was 4.2 days._x000D_ We employed 3-mm instruments in 11 surgeries. We did not perform clamping in 9 cases (82%). The average surgical time was 131,6 minutes, and the mean blood loss was 309 ml. The mean stay was 3.8 days. The complication was a urinary fistula that required nephrectomy (IIIb Clavien). The aesthetic results were satisfactory.
In our experience, retroperitoneoscopic acces with the use of 3 mm instruments provides an excellent access to the intrasinusal branches of the renal artery. In such a situation it is possible to perform zero ischemia time techniques in selected case.